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Perceptions of multiple chronic conditions and coping strategies among migrants from Sub-Saharan Africa living in France with diabetes mellitus and HIV: An interview-based qualitative study

PMCID: PMC10237665

PMID:

Abstract

Although diabetes is common among people living with HIV/AIDS (PLWHA), few data exists on how migrants from Sub-Saharan Africa (SSA) experience living with these two coexisting conditions in France. The objective of this study was to analyze perception of polypathology among PLWHA from SSA with type 2 diabetes and identify barriers and facilitators to their self-management. A qualitative study was conducted using semi-structured interviews from November 2019 to April 2020 with participants selected from a cohort of PLWHA and diabetes at Avicenne University Hospital. A total of 12 semi-structured interviews were conducted and analyzed using thematic analysis with inductive approach. Stigma remained a major issue in self-managing HIV, and some participants did not consider themselves as having a polypathology, as HIV has always been considered as a distinct condition. In general, emotion-based resources (e.g spirituality, trust in the medical discourse) and social support were mobilized more than problem-solving resources (e.g perception of medication as life-saving). Participants used the same main resource in self-management of HIV and diabetes, and resources used differed from participant to participant. This study highlighted challenges in self-management of diabetes and HIV in this population and complexity related to the socioeconomic and cultural specificities. Self-management could be more successful if patients and carers move in the same direction, having identified the individual coping resources to reach objectives.

Full Text

In France, nearly 6200 people discovered their HIV status in 2018, most of whom were born abroad (56%); among those born abroad, 66% were born in Sub-Saharan Africa (SSA) [1], reflecting the high proportion of migrants from SSA in France (47.5% as of 2021) [2]. Usually, many migrants from countries with limited resources, especially from SSA, encounter difficulties, in both the migration process and reception in the host country [3]. Despite relatively good health at the time of leaving their country of origin, this population is considered to be at high risk of developing health-related problems over time because of their irregular status and the effects of economic and social marginalization [4, 5]. Reportedly, socioeconomic conditions and access to health rights are the main risk factors for medical vulnerability in this population [6, 7].
Concerning HIV, migrants are at a higher risk of delayed diagnosis of HIV infection [8]. Indeed, 35% of migrant women and 45% of migrant men are diagnosed with advanced HIV disease (CD4 count below 200 cells/mL or AIDS-defining event) [9], and migrants account for 46% of people diagnosed with AIDS [10]. Late presentation, which may reflect late diagnosis and/or late entry into care, has consequences for the individual, in terms of poorer outcomes and mortality [11].
Universal access to antiretroviral therapy (ART) has remarkably decreased HIV-related mortality and increased the life expectancy of people living with HIV/AIDS (PLWHA) [12, 13]. Once associated with opportunistic diseases (infections that occur more often or are more severe in people with weakened than in people with healthy immune systems such as tuberculosis, toxoplasmosis…), HIV-related mortality is currently attributable to age-related comorbidities, including dyslipidemia, hypertension, and type 2 diabetes. Thus, half of the deaths of PLWHA are related to a non-AIDS cause, primarily cardiovascular [14]. However, several studies in the United States, Europe, and Africa have also demonstrated that ART also plays a role in the development of lipodystrophy, dyslipidemia, and diabetes [15, 16]. Depending on the study, the prevalence of diabetes among PLWHA varies between 2% and 14% [17, 18]. Along with multiple diseases, significant socioeconomic disparities exist in the occurrence of diabetes and its complications. A low socioeconomic level is a risk factor for developing diabetes with related consequences [19–23]. Thus, many migrants from SSA living with AIDS are now living with a polypathology, HIV and diabetes.
The emerging concept of polypathology is complex and broadly defined as the existence of two or more chronic conditions in the same individual [24].
Therapeutic patient education or self-management education [25] makes the patients an actor in their care by acquiring self-care and coping skills, thereby supporting patients with multiple diseases using programs that include educational tools or materials. In particular, it helps patients to fortify their coping strategies, as described by Lazarus and Folkman [26]. The term “coping” describes the actions that the patients develop to control, reduce, or tolerate difficult, stressful, or incomprehensible situations [27]. Thus, improving the self-management education of patients with polypathology warrants a better understanding of the barriers and facilitators. Some previous studies listed the main barriers of self-management as financial, logistical, and physical constraint, lifestyle changes, psychological consequences, poor family and social support; drug use; and the relationship with the healthcare system [28, 29]. On the side of the care system, facilitators of self-management have been identified as follows: health mediation, ethnopsychology, and care coordination [30].
Given the exploratory nature of this study, without any pre-specified hypothesis, a qualitative design, allowing an inductive approach was considered as the most appropriate. The inductive approach was used in order to identify new themes emerging from the participant’s discourse. The study was conducted in a hospital setting (Avicenne University hospital), given the health system characteristics in France, where PLWHA are mostly followed-up in large hospitals. The geographic area where the university hospital is located is the most deprived area of metropolitan France, with a large proportion of migrant population among the inhabitants. Indeed, the Avicenne Hospital is located in the department of Seine Saint Denis where nearly 30% of the population is immigrant [31]. The poverty rate in this department is the highest in metropolitan France (27.9% in 2015) [31].
Diabetes was defined as controlled for any HbA1c < 7% [32]. HIV control was defined as an undetectable HIV-1 RNA plasma level (< 40 copies of HIV per milliliter of blood) for at least 6 months. We chose as a criterion a diagnosis of diabete subsequent to that of HIV to study polypathology through the prism of HIV as an entry into the disease and to respect the same temporality between the two diagnoses. There was no a specific duration of time that the individual had to have had HIV and/or diabetes. We excluded diabetic participants on a single diet to assess the impact of polymedication in the self-management of polypathology.
The interview guide was first pilot-tested with one participant and further adapted as the interviews were transcribed and analyzed. Between analysis and data collection, the process was continuous, and the discovery of new elements in an interview led to the modification of the guide for subsequent interviews. S1 Annex presents the latest version of the interview guide used in this study.
Of note, participants were recruited until data saturation, which was discussed after each interview between the interviewer and supervisor and verified also with subsequent participants [33].
All interviews were transcribed using Microsoft Word software. The data were subjected to thematic analysis [34], with an inductive approach performed in parallel with the interviews to determine the end of recruitment when data saturation was attained. The interviewer performed the whole data analysis by manual open coding. It relied on the detailed reading of the raw data to bring out categories. In addition, double coding, with the help of the research supervisor, was done for two transcripts to increase the internal validity of the study. Then, an axial coding and finally a selective coding were performed by the researcher and the supervisor in order to identify the main themes presented in this paper. We identified first semantic themes and deepened the analysis towards latent themes. We followed COREQ guidelines for data analysis and data collection (S1 Checklist).
The interviews took place between 22thNovember 2019 and 5th January 2020. In total, 27 eligible participants were called, of whom 12 accepted the interview (see Table 1). All interviews were conducted in French. There was no repeat interview. The interview duration varied according to the personal time available to each participant and the ease with which they could share their experiences (one hour on average). Median age was 54 years old. The reasons for refusal were various (lack of time, poor understanding of French, and departure abroad). The range of year of arrival in France was between 1980–2007. Of all, 11 participants had controlled HIV infection, and 6 had controlled diabetes. Regarding the country of origin, three participants were from the Democratic Republic of Congo, three from Mali, three from Cameroon, one from Congo-Brazzaville, one from Côte d’Ivoire, and one from Senegal. Data saturation was reached after the 11th interview and we confirmed this hypothesis with the 12th interview during which no new information emerged. The analysis of the study yielded over 500 codes, which were then grouped into subthemes, themes, and then more general topics. We identified several themes and divided those into four categories: representation of two diseases (origin, perception of their severity, resources mobilized); self-management of the polypathology; and experience of the care pathway since the polypathology.
In some African cultures, blood also represents energy and spirit [35]). As HIV circulates in the blood, the representation of HIV as an invisible disease and an invisible spirit is also present.
When multiple providers were present, no participant was upset by some contradictions between practitioners, which is also not reported in the literature (but with different study populations) [24, 29, 36, 37].
In this study, emotion-based resources and social support were mobilized more than problem-solving resources, according to Cheng et al.’s classification [38]. Cheng et al looked at coping strategies for chronic conditions and classified them into two types: problem- and emotion-focused strategies.
The “drug” resource exerted an extremely positive, life-saving image, which is, for many, mobilized from one disease to another. Indeed, compliance with antiretroviral drugs was and is still essential for controlling HIV. There was a time when treatment was simply not available in many countries, especially in the SSA countries from which our participants came from. The only way out was death in the short or long term, which was one of the reasons for the strong stigma attached to HIV infection [39]. The “drug” enabled controlling HIV (the majority of participants had controlled HIV); thus, the same “drug” should also allow the control of diabetes. Nevertheless, the same resource that enabled HIV control was not available for diabetes self-management, as taking oral antidiabetic drugs was only one aspect of the treatment. Diabetes is far more difficult to control than HIV infection, especially as dietary measures are hard to apply.
The more difficult control of diabetes by taking drug alone seems to increase the perception of the severity of diabetes. Yet HIV is, overall, better controlled than diabetes. This result contradicts a 2011 French study on quality of life and perception of severity in HIV/diabetes HIV/diabetes comorbid patients [40]. In this study, 29 patients were asked about the perception of diabetes severity. Among hem, 93% of the patients had well-controlled HIV and only 22% had controlled diabetes. Yet, HIV is perceived as the main and most threatening disease for more threatening disease for more than half of the patients. This study was conducted in 2011 on patients not from SSA, showing that the perception evolves with time and the arrival of ARVs.
The social resources mobilized differed from one participant to another, but all mentioned one main resource (family,NGOs, or hospital), which is consistent with a study on the representation of HIV among migrants from SSA [39]. In particular, the relationship of trust in the medical world seems to be acquired with HIV and then reused for diabetes. By following the doctor’s rules and medicines, the disease can be fought. Moreover, we found that the relationship with the infectious disease specialist was very close for many, sometimes almost to the point of deification of their referent.
Whether the doctor–patient relationship mentioned above have a specificity among patients from SSA remains unclear. The idea of the physician as a savior and holder of knowledge is, perhaps, more deeply rooted in some cultures; however, the therapeutic physician–patient relationship in the management of HIV is especially strong and paramount in HIV-infected patients from SSA, as also shown in many studies [41, 42]. However, this result goes against the grain of the empowerment advocated by the scientific community and citizens, which leads patients to autonomy in health and better management of their illness [43].
The importance of NGOs resources in our sample corroborates the HIV literature. A retrospective study in Mozambique examining 1413 patients demonstrated a correlation between the absence of NGOs resources and nonadherence to ARV [44]. While this resource is essential in HIV self-management, it is not used in diabetes self-management. Although we did not find any literature on this subject, we formulated a few hypotheses: (i) patients miss this resource because they are not aware of it; (ii) the history of previous chronic disease, such as HIV, renders this resource cumbersome and redundant, preventing new recourse; (iii) the NGOs resource is often present to compensate for the family resource in the context of secrecy, but this same resource is no longer mobilized in the context of diabetes, an easily “dictated” disease. Although not widely used in our study, the value of NGOs for diabetes self-management has been well demonstrated in the literature. They have a major impact on improving clinical, lifestyle and psychosocial outcomes in people with Type 2 diabetes [45, 46].
Spirituality plays a key role, and it was cited as a common resource in HIV and diabetes in this study. Regardless of the religion (Muslim or Catholic), “God” gives meaning to the “disease” in terms of its cause, its evolution, and the means of accepting and fighting it, corroborating a Belgian study on a migrant population from SSA, where 46 patients (2 Muslims and 44 Christians) were asked about the role of religion in their HIV management; as in our study, a majority described God as a major factor impacting on their treatment and on the evolution of their pathology [47].
This resource, integrated with “emotion-based strategy” according to Cheng et al. [38], seemed to have a marked cultural dimension. Indeed, Leach and Schoenberg [48] suggested a clear difference in the expression and use of this resource between the two populations (Black Americans and White Americans). In addition, support from “God” and the church was central to the self-management of polypathology in the Black American population; one of the explanations for this was Taylor et al.’s model of the historical intertwining of religion and civil society in this population in many areas, including health [49].
In parallel with the stigma present within their religious community, this resource might raise questions about the need to intensify stigma prevention in this area. To date, numerous HIV prevention activities in different religious communities (mosques or churches) have been executed in France [50, 51] with a beneficial effect in terms of therapeutic education and control [52]. Concerning diabete, some church-based diabetes self-management education program have been described, especially for African-Americans with type 2 diabetes, which contribute to improve diabetes care in this population [52]. Indeed, few links exist between health professionals and these religious communities, which could play a major role in the quality of life related to HIV in patients from SSA.
For most participants, HIV remained a separate pathology, even within polypathology, primarily because of the stigma that HIV generates and the representation dominated by a certain link with death. In addition, our study aligns with a study conducted in Burkina Faso on 219 PLWHA on the different forms of stigmatization related to HIV [53]. Accordingly, several forms of stigmatization were highlighted: self-stigmatization (46%), stigmatization in interpersonal relationships (40%), and stigmatization in health services (11%) [53]. In our sample, self-stigma and interpersonal stigma were the main issues, and none of the participant mentioned stigma in the medical environment.
The diagnosis of diabetes is, for many, an entry into a “dictable” disease, which we can talk to others about, and participants acquire the social status of “being sick.” Once HIV is accepted and controlled (easily by medication), the severity shifts to diabetes. In our study, this perception of diabetes severity was objectified by less controlled diabetes than HIV. Previously, an American study on polypathology and HIV [28] in a predominantly Black American population reported that HIV was also perceived as less severe than diabetes, and the perception of diabetes as the most serious condition seemingly correlated with the integration of their medical discourse and the representation of diabetes through amputation. As with HIV, numerous studies demonstrated a close relationship between the representation of diabetes and involvement in this disease [54].
We found no study specifically on the representation of type 2 diabetes in migrants from SSA living in France. A qualitative English study examined the correlation between disease representation and diabetes management in patients from England and SSA and showed that diabetes self-management was hampered if diabetes was perceived as a disease with severe consequences in both populations [55]; our study confirms this result. As mentioned earlier, diabetes seems to be perceived as a hereditary disease with severe consequences that patients cannot control by themselves; thus, it is essential to change the representations of diabetes and provide access to more problem-based resources for the management of diabetes in particular.
Numerous studies in several countries mentioned the barrier to the organization of the healthcare system for patients with several diseases. An American qualitative study on polypathology and HIV reported difficulty in communication among practitioners as one of the barriers to managing polypathology [37]. Another study on barriers and resources to manage HIV and diabetes in Cape Town highlighted the need for integrated services that included management of all their conditions, therapeutic education materials, and improved information from practitioners about their condition [56]; our results contradict these findings. When a diabetologist or a GP was present, communication among doctors was not mentioned as a barrier, and no participant was bothered by certain contradictions among the different practitioners, which probably also related to a low level of literacy in its critical dimension. Indeed, other studies reported a significant discomfort related to contradictory medical discourses in populations with high literacy levels [57, 58].
This quasi-blind trust would be a specificity of our sample related to the onset of disease by HIV, which could create a particular doctor–patient relationship. Indeed, our study involved participants who already had a referral infectious diseases specialist with whom a bond of trust had often been established. Had our study included only participants who were initially diabetic and then diagnosed with HIV, the results could have been different. Furthermore, the issue of participants’ confidence in the French healthcare system and in their health professionals is a key resilience factor. A resilience factor can be described as the ability to achieve a goal despite a given ordeal [59].
A study in Ghana investigated the resilience factors HIV-infected patients that enabled them to engage and remain engaged in their care [57], reporting three factors, one of which was the appropriate level of trust in their health professionals. This doctor–patient relationship seems to be transposable from one pathology to another, which has implications in terms of the care pathway. The GP, who is supposed to play the main role in coordinating the care pathway, could play a much more central role than at present. If the diagnosis of these pathologies was done by a GP with more episodic follow-up by specialists, the trust could be built between the GP and these patients. Moreover, the perception of HIV could also be maintained by a predominantly hospital-based approach. Furthermore, the involvement of the GP from the moment of the diagnosis would, perhaps, make it possible to fight against stigmatization by demystifying the monitoring of PLWHA, followed by real integrated care.

Sections

"[{\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref001\", \"pone.0284688.ref002\", \"pone.0284688.ref003\", \"pone.0284688.ref004\", \"pone.0284688.ref005\", \"pone.0284688.ref006\", \"pone.0284688.ref007\"], \"section\": \"Introduction\", \"text\": \"In France, nearly 6200 people discovered their HIV status in 2018, most of whom were born abroad (56%); among those born abroad, 66% were born in Sub-Saharan Africa (SSA) [1], reflecting the high proportion of migrants from SSA in France (47.5% as of 2021) [2]. Usually, many migrants from countries with limited resources, especially from SSA, encounter difficulties, in both the migration process and reception in the host country [3]. Despite relatively good health at the time of leaving their country of origin, this population is considered to be at high risk of developing health-related problems over time because of their irregular status and the effects of economic and social marginalization [4, 5]. Reportedly, socioeconomic conditions and access to health rights are the main risk factors for medical vulnerability in this population [6, 7].\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref008\", \"pone.0284688.ref009\", \"pone.0284688.ref010\", \"pone.0284688.ref011\"], \"section\": \"Introduction\", \"text\": \"Concerning HIV, migrants are at a higher risk of delayed diagnosis of HIV infection [8]. Indeed, 35% of migrant women and 45% of migrant men are diagnosed with advanced HIV disease (CD4 count below 200 cells/mL or AIDS-defining event) [9], and migrants account for 46% of people diagnosed with AIDS [10]. Late presentation, which may reflect late diagnosis and/or late entry into care, has consequences for the individual, in terms of poorer outcomes and mortality [11].\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref012\", \"pone.0284688.ref013\", \"pone.0284688.ref014\", \"pone.0284688.ref015\", \"pone.0284688.ref016\", \"pone.0284688.ref017\", \"pone.0284688.ref018\", \"pone.0284688.ref019\", \"pone.0284688.ref023\"], \"section\": \"Introduction\", \"text\": \"Universal access to antiretroviral therapy (ART) has remarkably decreased HIV-related mortality and increased the life expectancy of people living with HIV/AIDS (PLWHA) [12, 13]. Once associated with opportunistic diseases (infections that occur more often or are more severe in people with weakened than in people with healthy immune systems such as tuberculosis, toxoplasmosis\\u2026), HIV-related mortality is currently attributable to age-related comorbidities, including dyslipidemia, hypertension, and type 2 diabetes. Thus, half of the deaths of PLWHA are related to a non-AIDS cause, primarily cardiovascular [14]. However, several studies in the United States, Europe, and Africa have also demonstrated that ART also plays a role in the development of lipodystrophy, dyslipidemia, and diabetes [15, 16]. Depending on the study, the prevalence of diabetes among PLWHA varies between 2% and 14% [17, 18]. Along with multiple diseases, significant socioeconomic disparities exist in the occurrence of diabetes and its complications. A low socioeconomic level is a risk factor for developing diabetes with related consequences [19\\u201323]. Thus, many migrants from SSA living with AIDS are now living with a polypathology, HIV and diabetes.\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref024\"], \"section\": \"Introduction\", \"text\": \"The emerging concept of polypathology is complex and broadly defined as the existence of two or more chronic conditions in the same individual [24].\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref025\", \"pone.0284688.ref026\", \"pone.0284688.ref027\", \"pone.0284688.ref028\", \"pone.0284688.ref029\", \"pone.0284688.ref030\"], \"section\": \"Introduction\", \"text\": \"Therapeutic patient education or self-management education [25] makes the patients an actor in their care by acquiring self-care and coping skills, thereby supporting patients with multiple diseases using programs that include educational tools or materials. In particular, it helps patients to fortify their coping strategies, as described by Lazarus and Folkman [26]. The term \\u201ccoping\\u201d describes the actions that the patients develop to control, reduce, or tolerate difficult, stressful, or incomprehensible situations [27]. Thus, improving the self-management education of patients with polypathology warrants a better understanding of the barriers and facilitators. Some previous studies listed the main barriers of self-management as financial, logistical, and physical constraint, lifestyle changes, psychological consequences, poor family and social support; drug use; and the relationship with the healthcare system [28, 29]. On the side of the care system, facilitators of self-management have been identified as follows: health mediation, ethnopsychology, and care coordination [30].\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref031\", \"pone.0284688.ref031\"], \"section\": \"Study design\", \"text\": \"Given the exploratory nature of this study, without any pre-specified hypothesis, a qualitative design, allowing an inductive approach was considered as the most appropriate. The inductive approach was used in order to identify new themes emerging from the participant\\u2019s discourse. The study was conducted in a hospital setting (Avicenne University hospital), given the health system characteristics in France, where PLWHA are mostly followed-up in large hospitals. The geographic area where the university hospital is located is the most deprived area of metropolitan France, with a large proportion of migrant population among the inhabitants. Indeed, the Avicenne Hospital is located in the department of Seine Saint Denis where nearly 30% of the population is immigrant [31]. The poverty rate in this department is the highest in metropolitan France (27.9% in 2015) [31].\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref032\"], \"section\": \"Study population\", \"text\": \"Diabetes was defined as controlled for any HbA1c < 7% [32]. HIV control was defined as an undetectable HIV-1 RNA plasma level (< 40 copies of HIV per milliliter of blood) for at least 6 months. We chose as a criterion a diagnosis of diabete subsequent to that of HIV to study polypathology through the prism of HIV as an entry into the disease and to respect the same temporality between the two diagnoses. There was no a specific duration of time that the individual had to have had HIV and/or diabetes. We excluded diabetic participants on a single diet to assess the impact of polymedication in the self-management of polypathology.\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.s002\"], \"section\": \"Interview guide\", \"text\": \"The interview guide was first pilot-tested with one participant and further adapted as the interviews were transcribed and analyzed. Between analysis and data collection, the process was continuous, and the discovery of new elements in an interview led to the modification of the guide for subsequent interviews. S1 Annex presents the latest version of the interview guide used in this study.\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref033\"], \"section\": \"Data collection\", \"text\": \"Of note, participants were recruited until data saturation, which was discussed after each interview between the interviewer and supervisor and verified also with subsequent participants [33].\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref034\", \"pone.0284688.s001\"], \"section\": \"Data analysis\", \"text\": \"All interviews were transcribed using Microsoft Word software. The data were subjected to thematic analysis [34], with an inductive approach performed in parallel with the interviews to determine the end of recruitment when data saturation was attained. The interviewer performed the whole data analysis by manual open coding. It relied on the detailed reading of the raw data to bring out categories. In addition, double coding, with the help of the research supervisor, was done for two transcripts to increase the internal validity of the study. Then, an axial coding and finally a selective coding were performed by the researcher and the supervisor in order to identify the main themes presented in this paper. We identified first semantic themes and deepened the analysis towards latent themes. We followed COREQ guidelines for data analysis and data collection (S1 Checklist).\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.t001\"], \"section\": \"Participants\\u2019 characteristics\", \"text\": \"The interviews took place between 22thNovember 2019 and 5th January 2020. In total, 27 eligible participants were called, of whom 12 accepted the interview (see Table 1). All interviews were conducted in French. There was no repeat interview. The interview duration varied according to the personal time available to each participant and the ease with which they could share their experiences (one hour on average). Median age was 54 years old. The reasons for refusal were various (lack of time, poor understanding of French, and departure abroad). The range of year of arrival in France was between 1980\\u20132007. Of all, 11 participants had controlled HIV infection, and 6 had controlled diabetes. Regarding the country of origin, three participants were from the Democratic Republic of Congo, three from Mali, three from Cameroon, one from Congo-Brazzaville, one from C\\u00f4te d\\u2019Ivoire, and one from Senegal. Data saturation was reached after the 11th interview and we confirmed this hypothesis with the 12th interview during which no new information emerged. The analysis of the study yielded over 500 codes, which were then grouped into subthemes, themes, and then more general topics. We identified several themes and divided those into four categories: representation of two diseases (origin, perception of their severity, resources mobilized); self-management of the polypathology; and experience of the care pathway since the polypathology.\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref035\"], \"section\": \"HIV: A disease of death and shame\", \"text\": \"In some African cultures, blood also represents energy and spirit [35]). As HIV circulates in the blood, the representation of HIV as an invisible disease and an invisible spirit is also present.\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref024\", \"pone.0284688.ref029\", \"pone.0284688.ref036\", \"pone.0284688.ref037\"], \"section\": \"Science that saves\", \"text\": \"When multiple providers were present, no participant was upset by some contradictions between practitioners, which is also not reported in the literature (but with different study populations) [24, 29, 36, 37].\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref038\"], \"section\": \"Resources mobilized in the self-management of HIV and diabetes\", \"text\": \"In this study, emotion-based resources and social support were mobilized more than problem-solving resources, according to Cheng et al.\\u2019s classification [38]. Cheng et al looked at coping strategies for chronic conditions and classified them into two types: problem- and emotion-focused strategies.\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref039\"], \"section\": \"Problem-solving strategies\", \"text\": \"The \\u201cdrug\\u201d resource exerted an extremely positive, life-saving image, which is, for many, mobilized from one disease to another. Indeed, compliance with antiretroviral drugs was and is still essential for controlling HIV. There was a time when treatment was simply not available in many countries, especially in the SSA countries from which our participants came from. The only way out was death in the short or long term, which was one of the reasons for the strong stigma attached to HIV infection [39]. The \\u201cdrug\\u201d enabled controlling HIV (the majority of participants had controlled HIV); thus, the same \\u201cdrug\\u201d should also allow the control of diabetes. Nevertheless, the same resource that enabled HIV control was not available for diabetes self-management, as taking oral antidiabetic drugs was only one aspect of the treatment. Diabetes is far more difficult to control than HIV infection, especially as dietary measures are hard to apply.\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref040\"], \"section\": \"Problem-solving strategies\", \"text\": \"The more difficult control of diabetes by taking drug alone seems to increase the perception of the severity of diabetes. Yet HIV is, overall, better controlled than diabetes. This result contradicts a 2011 French study on quality of life and perception of severity in HIV/diabetes HIV/diabetes comorbid patients [40]. In this study, 29 patients were asked about the perception of diabetes severity. Among hem, 93% of the patients had well-controlled HIV and only 22% had controlled diabetes. Yet, HIV is perceived as the main and most threatening disease for more threatening disease for more than half of the patients. This study was conducted in 2011 on patients not from SSA, showing that the perception evolves with time and the arrival of ARVs.\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref039\"], \"section\": \"Social support\", \"text\": \"The social resources mobilized differed from one participant to another, but all mentioned one main resource (family,NGOs, or hospital), which is consistent with a study on the representation of HIV among migrants from SSA [39]. In particular, the relationship of trust in the medical world seems to be acquired with HIV and then reused for diabetes. By following the doctor\\u2019s rules and medicines, the disease can be fought. Moreover, we found that the relationship with the infectious disease specialist was very close for many, sometimes almost to the point of deification of their referent.\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref041\", \"pone.0284688.ref042\", \"pone.0284688.ref043\"], \"section\": \"Social support\", \"text\": \"Whether the doctor\\u2013patient relationship mentioned above have a specificity among patients from SSA remains unclear. The idea of the physician as a savior and holder of knowledge is, perhaps, more deeply rooted in some cultures; however, the therapeutic physician\\u2013patient relationship in the management of HIV is especially strong and paramount in HIV-infected patients from SSA, as also shown in many studies [41, 42]. However, this result goes against the grain of the empowerment advocated by the scientific community and citizens, which leads patients to autonomy in health and better management of their illness [43].\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref044\", \"pone.0284688.ref045\", \"pone.0284688.ref046\"], \"section\": \"Social support\", \"text\": \"The importance of NGOs resources in our sample corroborates the HIV literature. A retrospective study in Mozambique examining 1413 patients demonstrated a correlation between the absence of NGOs resources and nonadherence to ARV [44]. While this resource is essential in HIV self-management, it is not used in diabetes self-management. Although we did not find any literature on this subject, we formulated a few hypotheses: (i) patients miss this resource because they are not aware of it; (ii) the history of previous chronic disease, such as HIV, renders this resource cumbersome and redundant, preventing new recourse; (iii) the NGOs resource is often present to compensate for the family resource in the context of secrecy, but this same resource is no longer mobilized in the context of diabetes, an easily \\u201cdictated\\u201d disease. Although not widely used in our study, the value of NGOs for diabetes self-management has been well demonstrated in the literature. They have a major impact on improving clinical, lifestyle and psychosocial outcomes in people with Type 2 diabetes [45, 46].\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref047\"], \"section\": \"Emotion-based strategies\", \"text\": \"Spirituality plays a key role, and it was cited as a common resource in HIV and diabetes in this study. Regardless of the religion (Muslim or Catholic), \\u201cGod\\u201d gives meaning to the \\u201cdisease\\u201d in terms of its cause, its evolution, and the means of accepting and fighting it, corroborating a Belgian study on a migrant population from SSA, where 46 patients (2 Muslims and 44 Christians) were asked about the role of religion in their HIV management; as in our study, a majority described God as a major factor impacting on their treatment and on the evolution of their pathology [47].\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref038\", \"pone.0284688.ref048\", \"pone.0284688.ref049\"], \"section\": \"Emotion-based strategies\", \"text\": \"This resource, integrated with \\u201cemotion-based strategy\\u201d according to Cheng et al. [38], seemed to have a marked cultural dimension. Indeed, Leach and Schoenberg [48] suggested a clear difference in the expression and use of this resource between the two populations (Black Americans and White Americans). In addition, support from \\u201cGod\\u201d and the church was central to the self-management of polypathology in the Black American population; one of the explanations for this was Taylor et al.\\u2019s model of the historical intertwining of religion and civil society in this population in many areas, including health [49].\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref050\", \"pone.0284688.ref051\", \"pone.0284688.ref052\", \"pone.0284688.ref052\"], \"section\": \"Emotion-based strategies\", \"text\": \"In parallel with the stigma present within their religious community, this resource might raise questions about the need to intensify stigma prevention in this area. To date, numerous HIV prevention activities in different religious communities (mosques or churches) have been executed in France [50, 51] with a beneficial effect in terms of therapeutic education and control [52]. Concerning diabete, some church-based diabetes self-management education program have been described, especially for African-Americans with type 2 diabetes, which contribute to improve diabetes care in this population [52]. Indeed, few links exist between health professionals and these religious communities, which could play a major role in the quality of life related to HIV in patients from SSA.\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref053\", \"pone.0284688.ref053\"], \"section\": \"Social legitimacy as a patient with a diagnosis of diabetes and severity that changes sides\", \"text\": \"For most participants, HIV remained a separate pathology, even within polypathology, primarily because of the stigma that HIV generates and the representation dominated by a certain link with death. In addition, our study aligns with a study conducted in Burkina Faso on 219 PLWHA on the different forms of stigmatization related to HIV [53]. Accordingly, several forms of stigmatization were highlighted: self-stigmatization (46%), stigmatization in interpersonal relationships (40%), and stigmatization in health services (11%) [53]. In our sample, self-stigma and interpersonal stigma were the main issues, and none of the participant mentioned stigma in the medical environment.\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref028\", \"pone.0284688.ref054\"], \"section\": \"Social legitimacy as a patient with a diagnosis of diabetes and severity that changes sides\", \"text\": \"The diagnosis of diabetes is, for many, an entry into a \\u201cdictable\\u201d disease, which we can talk to others about, and participants acquire the social status of \\u201cbeing sick.\\u201d Once HIV is accepted and controlled (easily by medication), the severity shifts to diabetes. In our study, this perception of diabetes severity was objectified by less controlled diabetes than HIV. Previously, an American study on polypathology and HIV [28] in a predominantly Black American population reported that HIV was also perceived as less severe than diabetes, and the perception of diabetes as the most serious condition seemingly correlated with the integration of their medical discourse and the representation of diabetes through amputation. As with HIV, numerous studies demonstrated a close relationship between the representation of diabetes and involvement in this disease [54].\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref055\"], \"section\": \"Social legitimacy as a patient with a diagnosis of diabetes and severity that changes sides\", \"text\": \"We found no study specifically on the representation of type 2 diabetes in migrants from SSA living in France. A qualitative English study examined the correlation between disease representation and diabetes management in patients from England and SSA and showed that diabetes self-management was hampered if diabetes was perceived as a disease with severe consequences in both populations [55]; our study confirms this result. As mentioned earlier, diabetes seems to be perceived as a hereditary disease with severe consequences that patients cannot control by themselves; thus, it is essential to change the representations of diabetes and provide access to more problem-based resources for the management of diabetes in particular.\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref037\", \"pone.0284688.ref056\", \"pone.0284688.ref057\", \"pone.0284688.ref058\"], \"section\": \"Implications for the care pathway in polypathology when one of the pathologies is HIV\", \"text\": \"Numerous studies in several countries mentioned the barrier to the organization of the healthcare system for patients with several diseases. An American qualitative study on polypathology and HIV reported difficulty in communication among practitioners as one of the barriers to managing polypathology [37]. Another study on barriers and resources to manage HIV and diabetes in Cape Town highlighted the need for integrated services that included management of all their conditions, therapeutic education materials, and improved information from practitioners about their condition [56]; our results contradict these findings. When a diabetologist or a GP was present, communication among doctors was not mentioned as a barrier, and no participant was bothered by certain contradictions among the different practitioners, which probably also related to a low level of literacy in its critical dimension. Indeed, other studies reported a significant discomfort related to contradictory medical discourses in populations with high literacy levels [57, 58].\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref059\"], \"section\": \"Implications for the care pathway in polypathology when one of the pathologies is HIV\", \"text\": \"This quasi-blind trust would be a specificity of our sample related to the onset of disease by HIV, which could create a particular doctor\\u2013patient relationship. Indeed, our study involved participants who already had a referral infectious diseases specialist with whom a bond of trust had often been established. Had our study included only participants who were initially diabetic and then diagnosed with HIV, the results could have been different. Furthermore, the issue of participants\\u2019 confidence in the French healthcare system and in their health professionals is a key resilience factor. A resilience factor can be described as the ability to achieve a goal despite a given ordeal [59].\"}, {\"pmc\": \"PMC10237665\", \"pmid\": \"\", \"reference_ids\": [\"pone.0284688.ref057\"], \"section\": \"Implications for the care pathway in polypathology when one of the pathologies is HIV\", \"text\": \"A study in Ghana investigated the resilience factors HIV-infected patients that enabled them to engage and remain engaged in their care [57], reporting three factors, one of which was the appropriate level of trust in their health professionals. This doctor\\u2013patient relationship seems to be transposable from one pathology to another, which has implications in terms of the care pathway. The GP, who is supposed to play the main role in coordinating the care pathway, could play a much more central role than at present. If the diagnosis of these pathologies was done by a GP with more episodic follow-up by specialists, the trust could be built between the GP and these patients. Moreover, the perception of HIV could also be maintained by a predominantly hospital-based approach. Furthermore, the involvement of the GP from the moment of the diagnosis would, perhaps, make it possible to fight against stigmatization by demystifying the monitoring of PLWHA, followed by real integrated care.\"}]"

Metadata

"{\"Data Availability\": \"Due to the vulnerable nature of the category of population which participated to the study (PLWHA, migrants and some being undocumented), and because in the information they were provided we mentioned that data will not be publicly shared to anyone else beyond the research team as asked by the Ethics committee, we will make available the transcripts upon request only. Data requests can be sent to the INSERM Ethics Committee via email (\"}"